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Official websites use. Share sensitive information only on official, secure websites. This article was submitted to Addictive Disorders, a section of the journal Frontiers in Psychiatry. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Background and Aims: COVID has infected more than 77 million people worldwide and impacted the lives of many more, with a particularly devastating impact on vulnerable populations, including people with substance use disorders SUDs. Given the lack of multicentric epidemiologic studies, we conducted a rapid global survey within the International Society of Addiction Medicine ISAM network in order to understand the status of substance-use patterns during the current pandemic. Participants: Starting on April 4, during a 5-week period, the survey received responses from 77 countries. Measurements: To assess addiction medicine professionals' perceived changes in drug and alcohol supply, price, use pattern, and related complications during the COVID pandemic. With respect to changes in use patterns, an increase in alcohol Conclusions: The global report on changes in the availability, use patterns, and complications of alcohol and drugs during the COVID pandemic should be considered in making new policies and in developing mitigating measures and guidelines during the current pandemic and probable future ones in order to minimize risks to people with SUD. Keywords: COVID, addiction, substance use disorder, global survey, behavioral addiction, illicit drug market. As of December 23, , the COVID pandemic has around 77 million cases of infection in more than countries with above 1,, overall deaths 1. Approximately 6 months after cases were first diagnosed, there remain few reliable treatments and no vaccines available, and an increasing number of countries are experiencing dangerous COVID transmission 2 , 3. Among vulnerable populations to infection and its complications are people with substance use disorders SUDs 4. Both comorbid medical conditions in SUDs such as cardiopulmonary diseases and related risk factors and drug—drug interactions between COVID medications and abused substances or SUD treatment medications , along with other factors, may lead to people with SUDs experiencing more complications when encountering COVID infections 4 — 6. People with SUDs are vulnerable given marginalization, stigmatization, and poor access to health and social services 7 , 8. Therefore, during the pandemic, gathering current information on the status of SUD is critical to support planning and mobilizing timely responses to minimize risks 4. Alterations in alcohol and drug supplies may change prices and availability and therefore use patterns. In the setting of COVIDrelated stressors, there may be decreases in drug and alcohol availability, increases in price and use patterns, and possible downstream effects on SUD presentations and treatment demands. Drug shortages, as the United Nation Office for Drug and Crime UNODC reports, could have negative health consequences regarding transitioning to consumption of harmful domestically produced substances along with more dangerous patterns of drug use including shifting to injections and using shared drug administration equipment, especially in the case of heroin 9. Concurrently, as legal liquor shops may remain closed during the lockdown in some countries, multiple problems may occur ranging from alcohol withdrawal to toxicity and death due to shifting to low-quality homemade liquor and accidental methanol ingestion 4 , For instance, as healthcare facilities become more difficult to access during lockdowns, people with SUDs may experience more difficulties relating to poor access to treatment centers. Socioeconomically disadvantaged backgrounds and diminished availability of public transportation may exacerbate such concerns 4 , 5 , 11 , especially for individuals receiving daily prescriptions of opioid substitution therapy 4. Professional authorities and health policymakers are expected to proactively address such emerging needs. However, the lack of reliable data complicates the generation and implementation of evidence-based policies. Although some activities and reports from different worldwide organizations have initially responded to the COVID pandemic, data provided have been limited and, in some occasions, as UNODC has reported, the information base for analyses has been restricted and feasibility of implementation unknown 1 12 — Thus, a vacancy exists for a comprehensive report describing the global situation with respect to drug use, drug supply, and related complications. In order to formulate a comprehensive health response, it is important to understand alcohol and drug markets' situation availability and price , use patterns and related complications, and how they may have changed during the pandemic. Designing a global in-depth epidemiologic study, apart from questions about its feasibility, is challenging during the pandemic. Therefore, the International Society of Addiction Medicine ISAM designed a comprehensive global survey and collected expert opinions on perceived changes in substance use situation and health system responses around the 1st week of April in what aims to be a longitudinal study Data related to the second section of the survey concerning substance use treatment and harm reduction services responses to the pandemic have been published recently We hypothesized that drug and alcohol use would increase, prices would increase, supply would decrease, and complications would increase and that results would differ by region given the differential spread of COVID and regional responses to the COVID pandemic. We hope that current data will help to address the urgent need for more accurate information about the status of drug and alcohol use in the current pandemic and provide information about appropriate modifications in health system services to respond to the emerging demands in the current pandemic and similar potential pandemics in the future. The complete study protocol has been previously published The ISAM mailing list and subsequent snowballing methodologies comprising addiction medicine professionals across the world were contacted on April 4, by email with an invitation to participate in the study by clicking on a link to the online survey. They also initially consented to be included as an author in the publications following the survey. Data collection was concluded on May 8, The questionnaire consisted of 92 questions in two main sections: 1 situational assessment during the pandemic and 2 health response to the pandemic. This paper provides an analysis of data obtained from the situation assessment section of the survey concerning changes in drug use, supply, price, risky behaviors, as well as related measures, namely morbidities, mortalities, and overdose rates during the COVID pandemic period in different countries Questions on the situational assessment section of the survey are available in Supplementary Method 2. The questionnaire was distributed in English for all the respondents. All statistical analyses were conducted using RStudio v. Descriptive data are presented as means and percentages for each country's response, as well as the average of the global responses. The survey protocols and all materials, including the survey questionnaires, received approval from the University of Social Welfare and Rehabilitation Sciences', ethics committee in Tehran, Iran Code: IR. Overall, respondents from 77 countries participated. Data from the rest of the respondents were analyzed. The list of the countries that provided information for this survey is available as a supplement Supplementary Method 1. Figure 1 depicts a map of the respondents' global distribution. Global distribution of the respondents to the survey. The survey involves respondents from 77 countries around the world, ranging from 1 to 13 participants from each country, demonstrated as a color spectrum from orange to dark red. Respondents consisted of males The mean age of the respondents was Information related to the respondents' main disciplines and academic degrees is shown Table 1. The demographic and professional information of survey respondents including their gender, age, academic degree, and primary discipline. Respondents provided information about drug use changes in their countries during the COVID pandemic. Perceived drug use changes by country are shown Figure 2 , Table 2. Details of drug use changes are reported in Supplementary Material. Changes in alcohol and drug use during the COVID pandemic reported by respondents from 77 countries globally. Countries' names are sorted in alphabetical order, and the number of respondents from each country is in parentheses following the country name. Each response is indicated as a single dot for no change or up and down triangles for increased and decreased answers, respectively, with a minor jitter for better visualization. Opioids: prescription opioids. Summary of the survey responses in different sections related to situational assessment including respondents' information about changes in alcohol and drug use pattern, supply, price, morbidity and mortality, and overdose. The bold values indicates highest rates of responses among respondents and countries. Respondents provided information about perceived drug supply changes in their countries during the COVID pandemic. The drug categories included the following: alcoholic beverages, cannabis including marijuana and synthetic cannabinoids such as spice, K2, etc. Decreased supply patterns for all substances were noted. Details of drug supply changes are reported in the Supplementary Material. Changes in alcohol and drug supply during the COVID pandemic reported by respondents from 77 countries globally. Respondents were asked to report changes the supply of alcohol, amphetamines, cannabis, cocaine, and opiates through the following options: Increased supply, decreased supply, no change , and I do not know. The mean of all responses, regardless of their originated countries and without considering those who did not know the answer, alongside the average answers of all countries, regardless of the number of respondents in each country, are addressed in the last two rows below the countries' names. Respondents provided information regarding perceived drug price changes in their countries during the COVID pandemic. Details of drug price changes are reported in the Supplementary Material. Changes in alcohol and drug prices during the COVID pandemic reported by respondents from 77 countries globally. Respondents were asked to report changes in alcohol, amphetamines, cannabis, and opiates prices through the following options: Price increased, Price decreased, Price did not change , and I do not know. Countries' names are sorted in alphabetic order, and the number of respondents from each country is in parentheses following the country name. The information related to changes in drug price among different countries is shown in Figure 4 and Table 2. Respondents provided information about whether morbidity and mortality, including fatal and non-fatal overdose rates, in their countries had changed during the COVID pandemic. Details of changes in mortalities and overdose rates are reported in the Supplementary Material. Changes in mortality, morbidity, and overdose in people with SUD during the COVID pandemic reported by respondents from 77 countries around the world. Respondents were asked to report changes in morbidity or mortality rates in people with SUD and changes in fatal and non-fatal overdose episodes through the following options: Increased, Decreased, I do not know, I do not like to answer , and Not applicable. Countries' names are sorted in alphabetical order, and the number of each country's respondents is mentioned in front of the names. The mean of all responses, regardless of their originated countries and without considering those who did not know the answer, alongside the average answers of all countries, regardless of the number of respondents in each country, are addressed in the last two rows below the countries' names SUD, Substance Use Disorder. Respondents reported an increase in behavioral addictions during the pandemic Supplementary Figure 1. Changes in risky behaviors including shifting to injection, using shared drug use equipment, needle sharing, and risky sexual behaviors during the COVID pandemic period, reported by respondents from 77 countries globally. Respondents were asked to report changes in risky behaviors injection, shared drug use equipment, needle sharing, and risky sexual behaviors through the following options: Yes, No, I do not know, I do not like to answer , and Not applicable. Countries' names are sorted in alphabetical order, and the number of each countries' respondents is mentioned in front of the names. The numbers of respondents who reported Yes or No answers to each question are demonstrated inside the bars If nothing is written, it indicates that there was only one response within Yes and No answers. The percentages shown by the bars are also based on only Yes or No answers. The mean percentages of all responses, regardless of their originated countries and without considering those who reported other than Yes and No answers, alongside the mean percentage answers of all countries, regardless of the number of respondents in each country, are addressed in the last two rows below the countries' names Risky Sex. Addiction medicine professionals were asked to report how seriously people with SUDs in their countries have been affected by the COVID pandemic using a range of between 1 and 1 representing Not affected , demonstrated with yellow at the beginning of the spectrum, and 10 representing Severely affected at the end of the spectrum, indicated with blue. Responses were collected beginning April 4, and through a 5-week period. They mostly believed that prices for alcohol and drugs have risen, and they have become less available during the pandemic. Most respondents reported increases in complications related to drug and alcohol use including increased morbidity and mortality in people with SUDs. Alterations in levels of alcohol consumption during pandemic are similar to those reported during prior social crises, like the — economic downturn Current reports from Australia indicate increases in purchases of alcoholic beverages during lockdown potentially due to the first mechanism However, India seems to be encountering a surge in numbers of individuals withdrawing from alcohol 5 , These independent reports from Australia and India are in line with our survey findings Figure 2. Initial reports from Australia and the United States indicate overall increases in alcohol sales, especially in online alcohol delivery subsectors 21 , although specific data from the industry on alcohol supply are largely lacking. However, there was no consensus among our survey respondents about changes in alcohol supply, as the responses that reported an increase, decrease, and no change were approximately equal. Approximately half of our survey respondents believed that there is no change in alcohol cost during the pandemic. This is while almost another half reported an increase in alcohol prices. We could not find any relevant reports indicating alcohol price alterations. Further data are needed as the pandemic progresses and hopefully resolves. There are currently concerns about morbidity and mortality spikes within people with AUDs and alcohol-associated liver disease during the pandemic The survey's results support the idea that these spikes can be seen among people with AUDs. Reports from Iran describe methanol poisoning of around 5, people with nearly deaths, which may be due to lack of education and illegal and uncontrolled alcohol sales because of alcohol bans in Iran 10 , 24 , However, to the best of our knowledge, there are yet no specific reports demonstrating the extent of alcohol overdose. The same pattern also applies to drug-related mortalities and morbidities. Survey results suggest increases in cannabis use in more than half of participating countries. The European Monitoring Centre for Drugs and Drug Addiction EMCDDA has investigated this matter through three large darknet markets 26 in the first 3 months of and reported overall increased market activity, mostly in relation to cannabis products 13 , This might show the initial effects of the pandemic on the European countries market, particularly before peaks in the number of people infected by COVID and subsequent widespread lockdowns. Opiates, amphetamines, and cocaine were generally reported to have a decrease or no change in patterns of usage in most countries. Although there are preliminary reports suggesting that opioid use is a risk factor for ICU admission in H1N1 infections and a possible risk factor for mortality following COVID infection, rumors about protective effects of opium use in Iran may have led to increased consumption 28 , In the US, an already severe opioid overdose crisis worsened since the COVID pandemic, with 30 out of 50 states reporting increases in overdoses between March and June of , with an increase in high potency synthetic opioids such as fentanyl in street supplies and decreased access to harm reduction and OUD treatment services cited as possible drivers of overdose increase 30 — While concerns have been also raised regarding probable effects of substances on COVID patients 4 , 33 , 34 , more research is needed on changes in drug use patterns and impacts on SUDs. Survey results also suggest increased use of prescription opioids, perhaps for similar reasons, and changes in services may be needed 35 , Canada, Australia, United Kingdom, and Scotland facilitated pharmacy-based methadone-dispensing programs as prescribing opioid-related medications increased This model may help to manage withdrawal syndromes during lockdown-related periods. In the United States, rapid changes in policies provided support to facilitate service delivery for people in opioid treatment programs, such as larger quantities of dispensed methadone and buprenorphine and relaxed regulations around virtual prescriber visits to initiate and continue medications for OUD in order to help patients access and maintain access to medications 35 , The EMCDDA has also noted that due to increases in the retail prices of cannabis and cocaine, the localized supply shortages may exist during the pandemic The UNODC has reported that across all regions globally, many countries have noted a general shortage of different drugs at the retail level, mostly due to reduction in imports or strict lockdown rules, resulting in fewer personal interactions for drug sales The UNODC has also noted a heterogeneous situation on bulk supply, both across drugs and across different countries Our results agree with multiple aspects of these reports of drug supplies. The UNODC reported that countries with strict rules on social distancing such as the Czech Republic, United Kingdom, Italy, and Iran have been facing increased street drug prices due to lack of availability Other reports from drug-producing countries suggest drug price decrements perhaps as a result of stockpiling of drugs Respondents mostly reported increases in behavioral addictions during the current pandemic, which may partly confirm the existing concerns on this matter 38 , Other small studies suggest increases in addictive behaviors 39 — Some forms of gambling may have decreased due to financial uncertainties, occupational problems, cessation of sporting events, closure of casinos, and other factors 40 , Discussing another addictive behavior, gaming has been represented to be a coping mechanism during the current stressful conditions Accordingly, gaming has increased among college students in India, who use gaming as an antistress mechanism Increased gaming has been occurring globally during the pandemic 43 , as well as pornography viewing These and other concerns have led to guidance about Internet use during the pandemic ISAM conducted the first global survey in the field of addiction medicine and successfully sampled responses from 77 countries and experts globally. This timely and rapid survey was designed in a multistep fashion including literature review, expert communication, professional qualitative appraisal, and finally a pilot study 17 and was able to rapidly and reliably address urgent gaps in knowledge during the current pandemic. However, there are limitations such as heterogeneity the numbers of respondents from different countries and their disciplines and educational levels. The convenience sample also may impact response rates and other factors. The lack of validated measures is a limitation, as is the lack of options for open-ended responses that would provide a window on the mechanisms driving reported trends. Given the dynamic nature of pandemics and lack of multicentric epidemiological studies, the survey is a timely approach to provide a snapshot of global clinical addiction medicine concerns during these unprecedented times. The objective of the ISAM survey was to provide initial, rapid preliminary evidence about how COVID has affected different situational aspects experienced by people with SUDs globally in order to help reach a better understanding of the current status. Provision of this information to international organizations and regional policymakers should help authorities plan for addressing urgent needs and providing suitable services not only in the current pandemic but also in future similar situations. To properly respond to the emerging demands and situational shifts during the COVID pandemic in the addiction treatment services across the world, at a macro policy level , it is critical to recognize the importance of 1 the social safety net and measures used to reduce the social inequality widening gap when such epidemics deteriorate an already vulnerable system, 2 responsive and publicly well-resourced healthcare with adequate supply of appropriate medication, 3 civil liberties, which could help increased participation and a judicious response by law enforcement agencies, and 4 policies that have taken in justifying alcohol sales and cannabis dispensaries as essential services and legislation allowing pharmacists to provide maintenance medications such as benzodiazepines in order to guarantee safe supplies. At a meso organizational level , it is important that clinical experience and knowledge on localized drug supply, price, and associated morbidities and mortality is shared within the organization in order to respond adequately. This makes it vital that organizations have a responsive continuity plan that can change with the needs of the population throughout the acute stage of the pandemic. It is also important to establish, support, and sustain varied digital platforms to allow better access to treatment for drug and alcohol using populations and minimize morbidities and possibly mortality. Establishing joint advocacy groups of service users and providers is also critical. In this unique global survey, experts in addiction medicine provided information on changes in regional alcohol and drug availability, price, usage, and related complications. Reduced availability may have generated increases in prices. Changed drug use patterns may not only impact people with SUDs but also give rise to risky behaviors and related complications. Most issues may potentially be preventable if future lockdown regulations are accompanied by enhanced service provision for at-risk communities. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The studies involving human participants were reviewed and approved by the survey protocols and all materials, including the survey questionnaires, received approval from the University of Social Welfare and Rehabilitation Sciences' ethics committee in Tehran, Iran Code: IR. The participants provided their written informed consent to participate in this study. ME and PR analyzed the data and ran the statistical analyses. All authors discussed the results, implications, and commented on the final manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Front Psychiatry. Find articles by Ali Farhoudian. Find articles by Seyed Ramin Radfar. Find articles by Hossein Mohaddes Ardabili. Find articles by Parnian Rafei. Find articles by Mohsen Ebrahimi. Find articles by Arash Khojasteh Zonoozi. Find articles by Mehrnoosh Vahidi. Find articles by Masud Yunesian. Find articles by Christos Kouimtsidis. Find articles by Shalini Arunogiri. Find articles by Helena Hansen. Find articles by Kathleen T Brady. Find articles by Marc N Potenza. Find articles by Alexander Mario Baldacchino. Find articles by Hamed Ekhtiari. Received Dec 25; Accepted Jun 15; Collection date Open in a new tab. Click here for additional data file. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Primary professional discipline.

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